Pediatric Examination and Board Review (183 page)

12.
(D)
According to CDC recommendations, all pregnant women should be screened at 35-37 weeks’ gestation for rectal and vaginal colonization for GBS. Intrapartum prophylaxis is indicated if there was a previous infant with invasive GBS disease, if the GBS screening culture is positive during the current pregnancy, or if the temperature is more than 100.4°F (38°C) with unknown GBS status. Colonization alone during a previous pregnancy is not an indication for intrapartum chemoprophylaxis unless screening results are positive in the current pregnancy.

TABLE 103-1
Features of Toxic Shock Syndrome Caused by
Staphylococcus Aureus and Streptococcus Pyogenes
(Gas)

Abbreviations: TSST-1, toxic shock syndrome toxin-1; SPE, streptococcal pyrogenic exotoxin.

13.
(A)
The enterococcus can cause neonatal infections as well as occasional infections in older children. In older children nosocomially acquired infection is not rare. Risk factors include indwelling central venous catheters, GI disease, immunodeficiency, cardiovascular abnormalities, and hematologic malignancy.
Enterococcus
spp. can occasionally cause meningitis, usually in neonates, and can occasionally cause urinary tract infections.

14.
(E)
In patients with disseminated gonococcal infection, isolation of
N gonorrhoeae
from a sterile site such as blood or joint fluid occurs in less than half of the patients. However, the organism can be isolated from a mucosal site or from a sexual contact in approximately 80% of cases. Ribosomal RNA detection is in wide use and has comparable sensitivity and specificity to the culture.

15.
(B)
A bite by a cat or a dog that results in cellulitis within 24 hours of the bite is most likely caused by
Pasteurella multocida
. Regional lymphadenopathy, fever, and chills are common. Tenosynovitis, septic arthritis, or osteomyelitis can also occur, associated with deeper bites by animals.
Eikenella
is an occasional culprit.

16.
(D)
Antimicrobial therapy is not indicated for uncomplicated
Salmonella
gastroenteritis in most cases because the therapy does not shorten the duration of disease and may prolong carriage. Children younger than 5 years have prolonged shedding with 40% excreting
Salmonella
in the stool for 20 weeks after onset of illness. Antimicrobial therapy for
Salmonella
gastroenteritis is indicated for certain groups of patients, including infants younger than 3 months as well as patients with chronic GI disease, malignancy, hemoglobinopathy, HIV infection or other immune deficiency or severe colitis.

17.
(A)
Even though the stool culture is negative for bacterial pathogens,
Shigella
is still the most likely pathogen. The sensitivity of stool culture for diagnosing
Shigella
dysentery in approximately 70%. Treatment for patients with
Shigella
is recommended for patients with severe illness or bacteremia, dysentery, or immunodeficiency.

18.
(B)
Infection caused by
Yersinia
is caused by ingestion of contaminated foods (pork intestine, milk, and other dairy products), by contaminated surface or well water, by direct or indirect contact with animals, or refrigerated stored blood. Infections in humans are more common in cooler climates during the winter months. Most likely, a caretaker handled the chitterlings and transmitted the pathogen to the infant.
Y enterocolitica
has also been reported to cause mesenteric adenitis, septicemia, meningitis, and postinfectious sequelae such as reactive arthritis, erythema nodosum, and uveitis.

S
UGGESTED
R
EADING

Long SS, Pickering LK, Prober CG, eds.
Principles and Practices of Infectious Diseases
. 3rd ed. Philadelphia, PA: Churchill Livingstone; 2008.

Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant
Staphylococcus aureus
in Los Angeles.
N Engl J Med.
2005;352:1445-1453.

Pickering LK, Baker CJ, Kimberlin DW, Long SS:
Red Book
:
2009 Report of the Committee on Infectious Diseases.
28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

CASE 104: A 13-YEAR-OLD ADOLESCENT BOY WITH A CHRONIC COUGH

A 13-year-old adolescent boy, who has been previously healthy, is brought to your office because he has had a persistent daytime and nighttime cough for the past 6 weeks. He had been diagnosed with pneumonia 4 weeks ago and treated with a 5-day course of azithromycin, then a 10-day course of amoxicillin-clavulanic acid, but there was little improvement. In addition, he has developed intermittent chest pain and a sensation of fever. He now has blood-tinged sputum.

On physical examination he is alert and cooperative. He is nontoxic in appearance. The temperature is 100°F (37.8°C). There are no skin lesions present. There is mild anterior and posterior cervical lymphadenopathy. The respiratory rate is 30/minute. The lung examination revealed decreased breath sounds over the left anterior and posterior chest. The examination of the heart and abdomen is normal.

SELECT THE ONE BEST ANSWER

1.
A chest radiograph is obtained, which reveals increased density in the inferior segment of the left lower lobe and marked interstitial disease in the left lower and right upper lobes. The left upper lobe is partially collapsed. A fungal culture of the sputum reveals no mycelia forms on smear, but the culture grows a few colonies of
Blastomyces dermatitidis
. The most common extrapulmonary manifestation of blastomycosis involves the

(A) skin

(B) bone and joints

(C) genitourinary tract

(D) heart

(E) CNS

2.
An 8-year-old girl from Indiana develops fever, cough, malaise, and chest pain. A chest radiograph reveals diffuse reticulonodular infiltrates with hilar adenopathy. You obtain the history that she was playing in a barn 2 weeks before the illness started. The most likely etiology of the child’s illness is

(A)
B dermatitidis

(B)
Histoplasma capsulatum

(C)
Mycobacterium tuberculosis

(D)
Paracoccidioides brasiliensis

(E)
Coccidioides immitis

3.
A 15-year-old girl develops a papule on the dorsum of her left hand that in a 2-week period enlarges and becomes indurated. The skin lesion then develops into a painless ulcer with formation of subcutaneous nodules and erythema involving the forearm. There is no response to antibacterial therapy. The most likely diagnosis is lymphocutaneous

(A) nocardiosis

(B) blastomycosis

(C) aspergillosis

(D) tuberculosis

(E) sporotrichosis

4.
A 14-year-old girl develops fever to 102°F (38.8°C), chest pain, and rash 2 weeks after returning from visiting relatives in Phoenix, Arizona. She took a few trips to desert areas outside Phoenix while visiting. On physical examination, she has fever of 102°F (38.8°C), and erythema nodosum is present on the lower extremities. A chest radiograph reveals a small right middle lobe infiltrate. Of the following, the pneumonia is most likely caused by

(A)
Aspergillus fumigatus

(B)
Histoplasma capsulatum

(C)
Candida glabrata

(D)
Coccidioides immitis

(E)
Blastomyces dermatitidis

5.
Congenital candidiasis can occur both in term and premature infants. The clinical manifestations in these two groups of patients differ in all the following features except

(A) premature infants require treatment with amphotericin B

(B) premature infants are more likely to have pulmonary involvement

(C) premature infants with candidiasis more often have a positive blood culture

(D) premature infants more often have a leukemoid reaction

(E) at birth both term and preterm infants have a diffusely erythematous popular rash

6.
A 7-year-old white girl has multiple hyperpigmented brown lesions with scaling that involve the upper trunk, proximal trunk, and neck. These are also a few scattered hypopigmented macular lesions on the face with fine scaling. You suspect
Pityriasis versicolor
. The etiologic agent of this skin disorder is

(A)
Malassezia furfur